Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse

OBJECTIVE: Our purpose was to assess the structural integrity of individual elements of the urethral and anterior vaginal wall support system. STUDY DESIGN: Notes were made during retropubic operations for cystourethrocele and stress incontinence in 71 women aged 52 +/- 12.4 (SD) years. Vaginal support was assessed with the Baden-Walker system with the following average findings: urethra 1.9 +/- 0.6, bladder 1.9 +/- 1.0, apex 0.8 +/- 1.1, upper posterior wall 0.3 +/- 0.8, and rectocele 1.1 +/- 0.7. The presence of the following features was noted: paravaginal defect, integrity of the pubic and ischial attachments of the arcus tendineus fascia pelvis (ATFP), appearance of the ATFP on the sidewall, and abnormalities in the pubococcygeal muscle. RESULTS: Paravaginal defects were present in 87.3% on the left and in 88.7% on the right. Detachment of the ATFP from the pubic bone was present in 1.4% (left) and 2.8% (right). The ATFP was detached from the ischial spine in 97.6% (left) and 95.1% (right). Remnants of the ATFP were present on the sidewall in 62% (left) and 63% (right). Of these, 9% extended one fourth the distance to the spine, 21% one half the distance, 3% three fourths the distance, and 17% all the way to the spine. The pubococcygeal muscle was visibly normal in 45% (left) and 39% (right). It showed localized atrophy in 22% (left) and 30% (right) and generalized atrophy in 22.5% (left) 30.0% (right). CONCLUSION: The ATFP usually detaches from the ischial spine, but not from the pubis; slightly less than half of these women have visibly abnormal levator an! muscles.